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DocuSign Envelope ID:42FC26E4-086D-47F4-A291-0A9A8706CA60 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> n) Program Budget <br /> 5. Submit your program budget. <br /> See attached <br /> 6. Program Budget Detail — Provide description of"other" budget items, not defined. <br /> Other Line items include contracted services, communications, printing and <br /> copying, community training, dues and subscriptions, participant incentives <br /> 7. This program budget represents what percent of the agency budget? 38% <br /> 8. COST PER INDIVIDUAL <br /> This Cost per Individual must reflect the total program budget divided by the total number of <br /> program individuals in this application. <br /> N <br /> Total Cost of Program $196,080 $216,730 $389,957 <br /> Total # of Individuals 314 400 400 <br /> Cost Per Individual $624 $542 $975 <br /> PROGRAM INFORMATION 1/31/2017 3:16:25 PM Page 2 4 of 32 <br />